Claims

Published 08/27/2024

How Do I File Part B Claims to Railroad Medicare?

  • File Electronically: Most providers submit electronic ANSI 837P claims
    • All providers must have a Railroad Medicare PTAN prior to enrolling with EDI. Please request a new PTAN or verify your current PTAN by using the Railroad Medicare PTAN Lookup and Request Tool.
    • Before filing claims electronically to Railroad Medicare, you must have an EDI enrollment packet on file with Palmetto GBA. See our Electronic Data Interchange (EDI) resources for more information on enrolling for electronic claim submissions.
    • View the Electronic Filing Instructions (PDF)
    • Palmetto GBA Interactive CMS-1500 Claim Form Instructions — This resource can also be helpful to providers who submit electronic claims. The help files for each CMS-1500 claim form field include the corresponding ANSI ASC 837P v5010 Loop, Segment, and Element, when applicable. 
       
  • File via Paper: Some providers that meet exceptions to mandatory electronic billing are allowed to submit CMS-1500 paper claim forms.
    • The Administrative Simplification Compliance Act (ASCA) requires that Medicare claims be sent electronically unless a provider qualifies for an exception waiver. To see if you qualify for an exception, please reference page six of the Medicare Learning Network (MLN) Booklet Medicare Billing Form CMS-1500 and the 837 Professional (PDF).
    • If you are required to submit electronically to your local Medicare Administrative Contractor (MAC), CMS requires you to submit electronically to Railroad Medicare, regardless of how many Railroad Medicare patients you may serve.
    • CMS Claim Filing Instructions
    • Palmetto GBA Interactive CMS-1500 Claim Form Instructions
    • Send paper claims to:

Palmetto GBA Railroad Medicare
P.O. Box 10066
Augusta, GA 30999-0001

Claims must be filed to the appropriate MAC no later than 12 months, one calendar year, from the date of service. Timely filing is determined by the date a processable claim is received by the appropriate MAC. Claims that are rejected as unprocessable are not considered submitted claims for the purposes of determining timely filing. Rejected claims must be corrected and resubmitted no later than 12 months from the date of service. Medicare will deny claims received after the deadline date. 

For more information on timely filing including the limited exceptions to the 12-month timely filing period, see IOM Pub. 100-04, Chapter 1 (PDF), Section 70, Time Limitations for Filing Part A and Part B Claims.

For information on submitting a request for a timely filing extension, see Checklist for Timely Filing Extension.

Part A — The jurisdictional A/B Medicare Administrative Contractors (A/B MACs) process hospital facility claims and skilled nursing facility claims for both Medicare and Railroad Medicare beneficiaries. You can use the CMS MAC Website List to find your local A/B MAC.

Home Health and Hospice — The four A/B MACs that process jurisdictional home health and hospice (HHH) claims process those claims for both Medicare and Railroad Medicare beneficiaries. You can use the CMS MAC Website List to find your local HHH MAC. 

Durable medical equipment (DMEPOS) — The jurisdictional DME Medicare Administrative Contractors (DME MACs) process claims for DMEPOS items for both Medicare and Railroad Medicare beneficiaries. You can use the CMS MAC Website List to find your local DME MAC. 

CMS publishes an annual DMEPOS Jurisdiction List on the Durable Medical Equipment (DME) Center page of their website. All HCPCS code listed are designated as under DME MAC or joint MAC Jurisdiction. 

Codes listed as under DME MAC jurisdiction should be billed to your local DME MAC for patients with Medicare and Railroad Medicare. 

Codes listed as under joint MAC jurisdiction include the criteria of when to bill to the Part B MAC and when to bill to the DME MAC. For example, “Part B MAC if used with implanted DME. If other, other, DME MAC.”

  • If a code is listed as under joint MAC jurisdiction and your claim meets the Part B MAC criteria, the code should be billed to Palmetto GBA Railroad Medicare for Railroad Medicare beneficiaries 
  • If a code is listed as under joint MAC jurisdiction and your claim does not meet the Part B MAC criteria, the code should be billed to your local DME MAC for patients with Medicare and Railroad Medicare

Any other codes not listed as DME MAC only or dual DME MAC/Part B MAC jurisdiction should be considered to be Part B MAC only jurisdiction and would be billed to Palmetto GBA Railroad Medicare for Railroad Medicare beneficiaries. 


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